Naguib El-Muttardi

Smoke inhalation increases intensive care requirements and morbidity in paediatric burns

Burn survival has improved with advancements in fluid resuscitation, surgical wound management, wound dressings, access to antibiotics and nutritional support for burn patients. Despite these advancements, the presence of smoke inhalation injury in addition to a cutaneous burn still significantly increases morbidity and mortality. The pathophysiology of smoke inhalation has been well studied in animal models. Translation of this knowledge into effectiveness of clinical management and correlation with patient outcomes including the paediatric population, is still limited. We retrospectively reviewed our experience of 13 years of paediatric burns admitted to a regional burns intensive care unit. We compared critical care requirements and patient outcomes between those with cutaneous burns only and those with concurrent smoke inhalation injury. Smoke inhalation increases critical care requirements and mortality in the paediatric burn population. Therefore, early critical care input in the management of these patients is advised.

Burns ITU admissions: length of stay in specific levels of care for adult and paediatric patients.

Prediction of total length of stay (LOS) for burns patients based on the total burn surface area (TBSA) is well accepted. Total LOS is a poor measure of resource consumption. Our aim was to determine the LOS in specific levels of care to better inform resource allocation. We performed a retrospective review of LOS in intensive treatment unit (ITU), burns high dependency unit (HDU) and burns low dependency unit (LDU) for all patients requiring ITU admission in a regional burns service from 2003 to 2011. During this period, our unit has admitted 1312 paediatric and 1445 adult patients to our Burns ITU. In both groups, ITU comprised 20% of the total LOS (mean 0.23±0.02 [adult] and 0.22±0.02 [paediatric] days per %burn). In adults, 33% of LOS was in HDU (0.52±0.06 days per %burn) and 48% (0.68±0.06 days per %burn) in LDU, while in children, 15% of LOS was in HDU (0.19±0.03 days per %burn) and 65% in LDU (0.70±0.06 days per %burn). When considering Burns ITU admissions, resource allocation ought to be planned according to expected LOS in specific levels of care rather than total LOS. The largest proportion of stay is in low dependency, likely due to social issues.

Use of biobrane® to dress split-thickness skin graft adjacent to skin graft donor sites or partial-thickness burns.

Biobrane® (Smith & Nephew Wound Management, Hull, United Kingdom) is a flexible biosynthetic wound dressing that has been widely used to dress partial-thickness burns and donor sites of split-thickness skin grafts (SSG).1–3 We reported 11 cases from March 2008 to March 2012 in which Biobrane was used to dress SSG, where the grafted areas were adjacent to donor sites or partial-thickness burns. Biobrane was used to dress SSG and their adjacent donor sites in five cases. In the other six described cases, we used Biobrane in mixed-depth burns. After tangential excision and skin grafting the deep burns, Biobrane was used to dress the SSG and adjacent superficial partial-thickness burns. Nine of the 11 cases were children. Biobrane was used to cover SSG over scalp, forehead, arms, legs, dorsum of foot, and abdomen. It was fixed with staples. An outer absorbent dressing was applied for 2 days, then Biobrane was left exposed (Figure 1). After removal of staples, Biobrane came off the sheet grafts on day 5 and it peeled off the meshed grafts, superficial burnt areas, and donor sites on days 10 to 14. In all reported cases, SSG fully took without complications, and patients were comfortable. Biobrane applied over SSG on flat and convex body surfaces promoted adherence of the SSG to the wound, prevented shearing, and allowed fluid drainage. Its transparency allowed regular checking without disrupting the graft, and at the same time facilitated healing of the adjacent donor sites or partial-thickness burns. In all cases, Biobrane was our first choice to dress the partial-thickness burns or SSG donor sites. By using the same dressing to cover the adjacent SSG, we negated the extra theater time needed when using different dressings; therefore, this method is cost-effective.

Microvascular free tissue transfer in acute and secondary burn reconstruction

INTRODUCTION The mainstay of operative treatment in burns is split skin grafting with free tissue transfer being indicated in a minority of cases. However, free tissue transfer faces a number of challenges in the burns patient. These include; overall cardiovascular and respiratory stability of the patient, availability of suitable vessels for anastomosis, sufficient debridement of devitalised tissue and a potentially increased risk of infection. We carried out a retrospective study in order to determine the indications, timing, principles of flap selection, complications, outcomes and methods of promoting flap survival when free tissue transfer was utilised for burn reconstruction in our unit. MATERIALS AND METHODS All patients who underwent soft tissue reconstruction for burn injuries with microvascular free tissue transfer between May 2002 and September 2014 were identified from our burns database. The records of these patients were then retrospectively reviewed. Data extracted included, age, gender, type of injury, total body surface area involved, indications for free tissue transfer, anatomical location, timing of reconstruction, complications and flap survival. RESULTS Out of a total of 8776 patients admitted for operative treatment over a 12-year period, 23 patients required 26 free flaps for reconstruction. Out of 26 free flaps, 23 were utilised for acute burn reconstruction while only 3 free flaps were utilised for secondary burn reconstruction. All 26 free flaps survived regardless of timing or burn injury mechanism. Complications included haematomas in 2 flaps and tip necrosis in 4 flaps. Two flaps required debridement and drainage of pus, 1 flap required redo of the venous anastomosis while 1 required redo of the arterial anastomosis with a vein graft. CONCLUSIONS Free tissue transfer has a small but definite role within acute and secondary burn reconstruction surgery. Despite the complexity of the burn defects involved, free flaps appear to have a high success rate within this cohort of patients. This appears to be the case as long as the appropriate patient and flap is selected, care is taken to debride all devitalised tissue and due diligence paid to the vascular anastomosis by performing it away from the zone of injury.

Burn Injuries Resulting from Hot Water Bottle Use: A Retrospective Review of Cases Presenting to a Regional Burns Unit in the United Kingdom

Introduction. Hot water bottles are commonly used to relieve pain and for warmth during the colder months of the year. However, they pose a risk of serious burn injuries. The aim of this study is to retrospectively review all burn injuries caused by hot water bottles presenting to our regional burns unit. Methods. Patients with burns injuries resulting from hot water bottle use were identified from our burns database between the periods of January 2004 and March 2013 and their cases notes reviewed retrospectively. Results. Identified cases involved 39 children (aged 17 years or younger) and 46 adults (aged 18 years or older). The majority of burns were scald injuries. The mean %TBSA was 3.07% (SD ± 3.40). Seven patients (8.24%) required debridement and skin grafting while 3 (3.60%) required debridement and application of Biobrane. One patient (1.18%) required local flap reconstruction. Spontaneous rupture accounted for 48.20% of injuries while accidental spilling and contact accounted for 33% and 18.80% of injuries, respectively. The mean time to heal was 28.87 days (SD ± 21.60). Conclusions. This study highlights the typical distribution of hot water bottle burns and the high rate of spontaneous rupture of hot water bottles, which have the potential for significant burn injuries.

A method of limb elevation during burn surgery

Elevation of limbs during burns surgery to access the posterior aspect is routinely required. We describe a method of limb holding during burns surgery using sharp towel clips fixed to the distal phalanges of a patients hands or feet. The limb is held in elevation using a sterile crepe bandage from the towel clips to a hook hung on a rail fixed to the theatre ceiling. We have used this technique for patients with extensive severe burns for many years with no significant damage to the nail beds or the tips of fingers and toes. This technique is convenient for surgeons as it allows easy access to hands and feet and the posterior aspects of arms and thighs. It is cost effective and safe as it spares an assistant and decreases the risk of potential occupational injury.Level of Evidence: Level V, therapeutic study.

Laser for Burn Scar Treatment

Abstract Restoration of form and function after burn injury remains challenging. Emerging laser and pulsed light technologies have been beneficial in the treatment of patients with hypertrophic scars, which may be associated with persistent hyperemia, chronic folliculitis, intense pruritus, and neuropathic pain. The following lasers have been used with varying levels of success in burn scar reconstruction: 1) vascular-specific pulsed dye laser (PDL) to reduce hyperemia, (2) ablative fractional CO 2 laser to improve texture and pliability of the burn scar, (3) ablative Erbium:YAG laser (4) lasers to target pigment including the ruby, NgYAG and Alexandrite lasers and (5) intense pulsed light (IPL) to correct burn scar pruritus, dyschromia, and alleviate chronic folliculitis. This chapter will briefly review the history of lasers, the physics of laser, and provide an overview of the different lasers utilized in burn reconstruction thus far. Additionally, at the end of this chapter, laser safety will be reviewed along with future directions for laser surgery in burn reconstruction.

Bubble bath burns: an unusual case

Abstract We present an unusual case of flash burn injury in an adolescent following accidental combination of foaming bath bubbles and tea light candle flame. There has not been any reported similar case described before. This serves as a learning point for public prevention and clinicians managing burn injuries.

Recurrent Metastatic Melanoma Despite Multiple Surgical Interventions and Biological Targeted Therapy

A 40 year old Caucasian male was referred to our plastic surgery unit with a rapidly growing mass in his left groin. A biopsy was taken which showed the lesion was metastatic amelanotic melanoma. No primary was identified. He had a history of a halo naevus on his lower back that had fully regressed

Pearls and pitfalls of laparoscopic harvest of omental flap for sternal wound reconstruction in patients with significant cardiac dysfunction

Laparoscopic omental harvest was first described by Saltz in 1993 and since then, it has been reported for sternal wound reconstruction following cardiac surgery. A laparoscopic approach eliminates the significant surgical trauma associated with laparotomy and decreases the risk of abdominal contamination. Furthermore, it results in reduced postoperative pain, earlier resumption of oral nutrition, lower rate of respiratory complications and therefore, it is conceivable that it is suitable especially for seriously ill patients with multiple co-morbidities. However, establishment of CO2 pneumoperitoneum required for the laparoscopic approach induces cardiac, pulmonary, renal, splanchnic and endocrine pathophysiological changes. Notably, CO2 pneumoperitoneum can adversely affect cardiac performance by stimulating a neurohormonal response that increases systemic vascular resistance and heart rate, and decreases venous return. Such changes are poorly tolerated by patients with underlying cardiac dysfunction and may increase the risk of cardiac complications perioperatively. We performed reconstruction of sternal defects with omental flaps in 8 patients (Table 1) with significant cardiac dysfunction following deep sternal wound infection after coronaryarterybypassgrafting.The laparoscopicharvestwas conducted through four 5 mm operating ports (Figure 1). Pneumoperitonium was established by insufflating with carbon dioxide (CO2) up to 12 mmHg at rate of 5 L/min. Upon insufflation, one patient developed hypotension necessitating intravenous infusion of vesopressor agents. Another patient developed supraventricular tachycardia and required amiodarone infusion. Both incidences necessitated immediate desufflation and conversion to laparotomy for omental